Method of managing joint pain

ABSTRACT

A method of alleviating joint pain in a patient comprising evaluating the patient&#39;s joint pain when undergoing motions associated stress to the joint, and injecting the patient with a peptide of SEQ ID No. 1, and thereafter evaluating the patient&#39;s joint pain when undergoing the same motion.

FIELD OF THE INVENTION

The invention relates generally to methods for alleviating joint painand specifically to alleviating joint pain in a patient duringparticular types of movement that exert pressure on the joint.

BACKGROUND

Joint pain is one of the major quality of life problems. Depending onwhich joint suffers from pain, it limits and sometimes totally disablesmovements or performance of specific works in daily living. If onesuffers from pain in a joint in a leg such as hip, knee, and ankle, itlimits leg movements and not only for hard activities such as runningand jumping but routine ones such as walking and ascending or descendingstairs. If one feels pain in one or more joints in her/his fingers,opening a cap of a container will become a challenging task.

While joint pain can be caused by a variety of reasons, includingsometimes non-pathologic reasons, the most common cause is arthritis.According to the Center for Disease Control and Prevention March 2017Vital Signs announced data estimating that 54.4 million U.S. adultssuffer from arthritis, equating to about 25% of the population. The mostcommon types of arthritis are osteoarthritis (OA), rheumatoid arthritis(RA), and gout. The data by the Center for Disease Control andPrevention also indicate that there are approximately 27 million OA and1.3 million RA patients in the U.S. alone. Joint injury is another majorcause of joint pain.

Osteoarthritis is the most common disease of the joints, and one of themost widespread of all chronic diseases. In the US, osteoarthritis (OA)is second only to heart disease as a cause of work disability in menover 50 years of age. Osteoarthritis was the 6th leading cause of yearsliving with disability at a global level, accounting for 3% of the totalglobal years of living with disability (Woolf 2003).

Approximately 80% of OA subjects need treatment in the knee. Within theknee joint of symptomatic individuals, the most common radiographicpattern for osteoarthritis is loss of articular (hyaline) cartilage andunderlying subchondral bone, often with osteophyte formation at thejoint margins. Both the tibio-femoral and patello-femoral compartmentsare commonly affected by degenerative changes. Patello-femoral arthritisdue to loss of cartilage of the patella and trochlear groove is commonin subjects with knee OA, whether or not other joint compartments haveOA (Davies 2002, Lankhorst 2017).

Pain is a common subjective symptom in subjects with knee OA. Paintypically is treated with acetaminophen or non-steroidalanti-inflammatory drugs (NSAIDs). In addition, two types ofintra-articular treatments, corticosteroids and hyaluronic acidproducts, also are used for pain control. Corticosteroid injections havebeen associated with further cartilage degeneration (McAlindon 2017),and are used less commonly than they used to be.

The hyaluronic acid products, or “viscosupplementation” products, areinjected into the knee either in once-weekly divided doses (2 cc) for 3weeks, or in a single larger dose (6 cc; Chevalier 2010). It is claimedfor joint pain reduction for weeks to months (Cohen 1998), but multipleclinical trials failed to demonstrate their clinically meaningfulefficacy. American Academy of Orthopaedic Surgeons/American Associationof Orthopaedic Surgeons (AAOS) has issued, in its knee osteoarthritistreatment guideline published on May 18, 2013, a strong recommendation,which states, “We cannot recommend using hyaluronic acid for patientswith symptomatic osteoarthritis of theknee.”(http://www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideline.pdf) AAOS does not recommend use of corticosteroid injections, either, inthe same guideline. Also, neither hyaluronic acid products norcorticosteroids are disease modifying.

Human articular (joint) cartilage is a unique tissue composed ofchondrocytes embedded in an extracellular matrix of type II collagen,non-collagenous proteins, water, and specific proteoglycans.Proteoglycans contain various chondroitin and heparin sulfate groupswhich are able to be highly hydrated. This high degree of hydration is,to a large degree, what gives hyaline cartilage its resilience tocompression and ability to buffer biomechanical stress. Articularcartilage is designed to enable smooth, almost frictionless movement ofjoint surface and to cushion long-term cyclic loads as well as off-setshear forces on the joint. The unique biomechanical properties ofarticular cartilage have never been matched by any artificial material,and are unmatched by fibrocartilage (“scar” cartilage) formed aftermicrofracture surgery or other injuries. Unfortunately, articularcartilage does not regenerate naturally, neither after trauma nor in thesetting of chronic “wear and tear” of aging (Buckwalter 2002).

Articular cartilage is a unique tissue in that it has no blood or nervesupply, and no inter-cellular connections. Typically, cartilage consistsof water (c.a. 70%), extracellular matrix molecules such as Type IIcollagen and proteoglycan (c.a. 25%), and chondrocytes (c.a. 5%).

Thus far, only surgical methods and symptomatic (pain) management havebeen approved for subjects suffering with knee OA. Surgically,microfracture is used to induce formation of fibrocartilage (scarcartilage) by allowing bone marrow cells to infiltrate cartilagedefects. However, fibrocartilage has much less structural strength andstability than normal articular cartilage and degenerates more quickly.Other invasive surgical procedures used for cartilage repair in the kneeinclude drilling into subchondral bone and implanting plugs of cartilagecells (chondrocytes) or their progenitor cells that have been taken fromnon-weight-bearing parts of the subject's body or from a cadaver(osteochondral autograft/allograft transplantation, OATS procedure). Twosurgeries are required, and the subject cannot return to fullweight-bearing for approximately 6 weeks after the procedure. Treatmentfailures are common, as is the need for additional surgery forcomplications.

Two surgical procedures also are required for the autologous chondrocyteimplantation (ACI), where healthy cartilage is harvested from the kneearthroscopically and grown in culture; then the cultured chondrocytesare implanted in open knee surgery where the cartilage is cut (debrided)down to the bone, either a periosteal for bioengineered flap is stitchedor glued into place and the new cells are injected into the flap. In thepublished Carticel® study of more than 150 subjects with ACI, 49% ofsubjects required repeat surgery for various complications such as graftfailure or delamination (Zaslav 2009). Complications includedelamination, graft failure, and disturbed fusion (Niemeyer 2008).

The most invasive option thus far for subjects with disabling knee OA isjoint replacement surgery, an expensive option with potential forserious morbid complications. Total knee replacement of one knee costs$35,000-70,000, which does not include the cost for a long (at least 6weeks) rehabilitation process after the surgery and economical lossduring the disabled period. This surgery is usually reserved for oldersubjects, since the prosthetic joint has a limited life expectancy andtypically must be replaced after about 15 to 20 years.

Clearly a treatment that is safe, office-based, administered by familiarintra-articular injection methods, and that can promote regeneration ofnormal articular cartilage would address a critical unmet need. Theregeneration of knee cartilage with normal morphological andbiomechanical characteristics would not just delay or eliminate the needfor invasive and expensive surgeries, including total knee replacement,but significantly improve the functions of the knees, therebysignificantly reduce the disability associated with knee OA, as well asthe loss in productivity that accompanies functional impairment.

Most joint health problems are due to either osteoarthritis (OA),rheumatoid arthritis (RA), or joint trauma. It is widely accepted that acommon outcome of these conditions is cartilage damage The patients withthese conditions often suffer from limited joint mobility and function,presumably due to cartilage damage in the joint. If the damagedcartilage is repaired, the patient should be able to anticipate smoothermovement of the joint.

A key issue associated with damaged joints is pain. According to ananalysis of the Osteoarthritis Initiative (OAI) database, there is nocorrelation between the degree of cartilage damage and severity of jointpain experienced individuals (Bedson and Croft, BMC MusculoskeletalDisorders 2008, 9:116 doi: 10.1186/1471-2474-9-116). A person can haveextreme joint pain with little or no observable cartilage damage in saidjoint. On the other hand, another person may feel little or no paindespite clear evidence of severe cartilage damage or destruction.

Articular cartilage does not have any neurons or vascularization.Although chondrocytes (cartilage cells) are embedded in the tissue,there are no inter-cellular connections as there are in bone forexample. Therefore, cartilage repair should not directly influence jointpain. The only theoretical possibility where cartilage repair couldalleviate pain is rebuilding a new cartilage tissue over exposedsubchondral bone. However, as described above, no correlation has beenfound thus far between the cartilage damage or subchondral bone exposureversus severity of joint pain.

Joint pain is a major quality of life problem, with or without anyapparent joint pathology such as OA, RA, or joint trauma. Although theseconditions are commonly treated by anti-inflammatory agents oranalgesics such as non-steroidal anti-inflammatory agent oracetaminophen, their efficacy is limited. In more extreme cases, someindividuals use opioids to control the pain. However, opioid abuse hasled to more stringent prescribing regulations, and opioids are notgenerally considered appropriate for long term pain management.

Peptide Injection

TPX-100 is a synthetic peptide consisting of 23 amino acids with aminoacid sequence of TDLQERGDNDISPFSGDGQPFKD (SEQ ID No. 1), derived fromhuman Matrix Extracellular Phosphoglycoprotein, or MEPE. TPX-100 hasbeen shown to promote tissue-appropriate regeneration of cartilage,bone, and dentin without any soft tissue calcification or ossification.TPX-100 can be administered by conventional methods such as subcutaneousor intra-articular injection.

In non-clinical safety and efficacy studies, cartilage regenerationproperties of TPX-100 have been demonstrated in the goat model ofstandardized large cartilage defects. In a full-thickness chondraldefect model in weight-bearing goats, a regimen of four weeklyintra-articular (IA) injections of TPX-100 (125 mg and 250 mg) wasassociated with histologically-confirmed and statistically significantarticular cartilage regeneration at 6 months post-surgery compared tocartilage regeneration in the vehicle control group. The drug was safeand well-tolerated in these freely ambulatory animals (See U.S. Pat. No.8,426,558). Safety of the TPX-100 peptide was further confirmed inmultiple GLP toxicology studies, as well as multiple Phase 1 and Phase 2clinical studies involving systemic and local injections of the drug.

Based on these safety and articular cartilage regeneration efficacydata, a randomized, double-blind, placebo-controlled clinical study ofTPX-100 with the subjects with osteoarthritis of the knees wasperformed. Successful clinical development of TPX-100 could result inits selection as the first-line treatment for OA, prior to surgicaloptions. TPX-100 has the potential to reduce significantly thedisability associated with knee OA as well as the loss in productivitythat accompanies functional impairment. Significant improvement in kneefunctions was particularly anticipated as the primary knee health effectby adequate repair of knee cartilage.

The TPX-100 drug substance was manufactured as the acetate saltlyophilized powder with the C-terminus amidated. The TPX-100 injection(drug product) used in the clinical study was formulated in a salinesolution of pH7.

The TPX-100 drug substance is also manufactured as the sodium saltlyophilized powder utilizing the amidated C-terminus. This sodium saltis being used in the latest lyophilized formulation of TPX-100, which isreconstituted with water for injection (WFI) before its therapeutic usein humans or other species.

SUMMARY OF THE INVENTION

A method of alleviating joint pain associated with activities that exertstress or pressure on the joint is disclosed. The method comprisesinjecting the patient with a formulation of a peptide of SEQ ID No. 1 ina therapeutically effective amount.

In an important aspect of the invention, method of alleviating knee painassociated with activities that exert a high degree of stress orpressure on the knee such as climbing stairs is disclosed. The methodcomprises injecting the patient with a formulation of a peptide of SEQID No. 1 in a therapeutically effective amount.

An aspect of the invention is alleviating knee pain in a patient whereinthe pain alleviation is focused on situations where the patient isexerting pressure on the knee and bending the knee in a manneralleviating knee pain in a patient while the patient needs to exert morepressure on the knee such as going up or down stairs. The methodincludes diagnosing the patient that is experiencing knee pain duringsuch movement, and then administering to the patient a formulationcomprised of a therapeutically effective amount of a peptide of SEQ ID.No. 1.

The peptide is formulated into an injectable formulation, which caninclude water or saline solution and be injected locally into the jointsuch as a knee joint subcutaneously or intra-articular.

In an aspect of the invention, the method is carried out with theinjection being administered only once, only twice, three times, fourtimes, five times, etc. The dosing may be delivered daily, every threedays, once a week, every ten days, every other week, once a month, everyother month, every three months, every six months, once a year, ordifferent combinations thereof. Injection can be local or systemic. Itcan be intra-articular, subcutaneous, intramuscular, or intravenous.Injection is not an only way for administration. The peptide of SEQ ID.No. 1 can be administered with a biodegradable matrix carrier such ascollagen sponge, hyaluronic acid, alginate, and so forth, and suchcombination can be implanted into a cartilage defect or injected intothe knee or any other joint with pain.

In an aspect of the invention, the method is used to treat any jointpain regardless of its bottom-line pathology. It can be used to treatjoint pain caused by osteoarthritis (OA), rheumatoid arthritis (RA),gout, joint injury, or any other causes insofar as they result in jointpain.

In an aspect of the invention, the method includes follow up evaluationof the patient's knee pain using systems such as the pain subscale ofknee injury and osteoarthritis outcome score (KOOS). The evaluation mayalso be carried out based on any other patient reported outcome (PRO)assessing the severity of knee pain, including but not limited to thepain subscale of Western Ontario and McMaster UniversitiesOsteoarthritis Index (WOMAC) and numerical rating scale of pain (NRS).If the patient's pain is not in the knee but other joint, a painevaluation system applicable to the joint may be used. Broadly used painevaluation systems are visual analogue scale (VAS), visual rating scale(VRS), and NRS. Also, there are other joint-specific pain scales. Forexample, if the target joint to treat the pain is hip, hip disabilityand osteoarthritis outcome score (HOOS) may be used.

In an aspect of the invention, the dosing may be in a range of from 20mg to 1,200 mg, or 25 mg to 600 mg, 100 mg to 400 mg, or 200 mg, whereinall milligram doses are ±20%, ±10%, ±5%.

In an aspect of the invention, the patient with knee pain is firstevaluated based on whether or not they feel knee pain, particularly whenthey bend their knees.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

combining water with a peptide consisting only of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1); and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject absentobservable damage in cartilage of the joint.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

combining water with a lyophilized powder of a peptide consisting onlyof an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1); and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject absentdetectable damage in cartilage of the joint.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a powder of a peptide consisting only of an aminoacid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1); and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

combining water with lyophilized powder of a peptide consisting only ofan amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) thesequence comprising an amidated C-terminus to create an injectableaqueous formulation; and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting only of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) to create an injectable aqueousformulation; and

injecting a joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a sodium salt lyophilized powder of a peptideconsisting only of an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ.ID No:1) the sequence comprising an amidated C-terminus to create aninjectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a lyophilized powder of a peptide consisting onlyof an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) thesequence comprising an amidated C-terminus to create an injectableaqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting only of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) to create an injectable aqueousformulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a sodium salt lyophilized powder of a peptideconsisting only of an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ.ID No:1) the sequence comprising an amidated C-terminus to create aninjectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject absent anyobservable change in cartilage of the knee joint after the injection.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a sodium salt lyophilized powder of a peptideconsisting only of an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ.ID No:1) the sequence comprising an amidated C-terminus to create aninjectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a lyophilized powder of a peptide consisting onlyof an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) thesequence comprising an amidated C-terminus to create an injectableaqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting only of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) the sequence comprising anamidated C-terminus to create an injectable aqueous formulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing knee joint pain in asubject, comprising:

combining water with a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1) to create an injectable aqueousformulation; and

injecting a knee joint of the subject with the injectable aqueousformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention includes a method of treatment or a use for acomposition as described herein wherein the peptide of SEQ ID No: 1 isadministered (intra-articular injection) in an aqueous formulationcomprising water for injection (WFI) in an amount in a range of 100 mgto 400 mg wherein the injection is intra-articular, wherein theformulation is created by mixing the WFI with a lyophilized powder ofthe peptide of SEQ ID NO: 1 just prior to injection, and further whereinthe formulation may be injected in an amount of 200 mg per injectionevery five days, week, 10 days, 15 days pro re nata (PRN) for a periodof two, three, four or five injections or more after which the resultsare evaluated on a pain subscale of either or both of WOMAC or KOOSand/or using a numerical rating scale for pain (NRS).

An aspect of the invention is a method as described above, furthercomprising:

diagnosing the patient as experiencing joint pain when the patient isundergoing an activity which requires a stress to the joint.

An aspect of the invention is a method as described above, where theactivity which requires a stress is a greater degree of knee bendingthan necessary to walk on a flat surface.

An aspect of the invention is a method as described above, where theactivity is going up or down stairs.

An aspect of the invention is a method as described above, where thepatient suffers from at least one of the following conditions in thepainful joint: osteoarthritis, rheumatoid arthritis, or joint trauma.

An aspect of the invention is a method as described above, whereby thepatient is diagnosed as experiencing less pain going up or down stairsafter the injecting.

An aspect of the invention is a method for reducing the frequency ofoverall joint pain experienced by a subject, comprising:

injecting a joint of the subject with the injectable aqueous formulationcomprising an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. IDNo:1),

evaluating joint pain in the subject 12 months or earlier afteradministering the formulation,

whereby the formulation reduces joint pain in the subject absent anyobservable change in cartilage of the joint.

While it may take months to reduce the frequency of joint pain after theinitial treatment of the joint with the formulation, the pain should beconsistently controlled when the treatment is continued with reasonableintervals such as once every 6 months or once a year—pro re nata (PRN).

An aspect of the invention is a method for reducing the frequency ofoverall joint pain experienced by a subject, comprising:

injecting a joint of the subject with the injectable aqueous formulationcomprising an amino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ. IDNo:1),

evaluating joint pain in the subject after administering theformulation,

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method as described above where thejoint is knee.

An aspect of the invention is a method as described above wherein theinjection is intra-articular.

An aspect of the invention is a method as described above wherein thepeptide of SEQ ID NO: 1 is administered in combination with hyaluronicacid.

An aspect of the invention is a method as described above wherein thepeptide is administered in a dose in a range of 20 mg to 1,200 mg perone injection.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

injecting a joint of the subject with an injectable aqueous formulationcomprising a peptide consisting only of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1),

whereby the formulation reduces joint pain in the subject.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

making a first evaluation of knee pain of the patient using a painsubscale of Western Ontario and McMaster Universities OsteoarthritisIndex (WOMAC);

injecting a knee joint of the subject with an injectable aqueousformulation comprising a peptide consisting only of an amino acidsequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1),

making a second evaluation of knee pain of the patient using a WOMAC;

whereby the formulation reduces joint pain in the subject based onWOMAC.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

making a first evaluation of the patient's knee pain using a painsubscale of knee injury and osteoarthritis outcome score (KOOS);

injecting a knee joint of the subject with an injectable aqueousformulation comprising a peptide consisting only of an amino acidsequence TDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1),

making a second evaluation knee pain of the patient using a KOOS;

whereby the formulation reduces knee joint pain in the subject based onKOOS.

An aspect of the invention is a method for managing joint pain in asubject, comprising:

making a first evaluation of the patient's joint pain using a suitablepatient reported outcome to said joint;

injecting a joint of the subject with an injectable aqueous formulationcomprising a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1),

making a second evaluation knee pain of the patient using the samepatient reported outcome;

whereby the formulation reduces knee joint pain in the subject based onthe same patient reported outcome.

Examples of the patient reported outcome usable to evaluate patient'sjoint pain other than WOMAC and KOOS include Numerical Rating Scale,Visual Analogue Scale, Visual Rating Scale, Brief Pain Inventory,Descriptor Differential Scale, Lequesne-Algofunctional Index, MankoskiPain Scale, McGill Pain questionnaire, Oswestry Disability Index, andVerbal Rating Scale.

An aspect of the invention is a method for managing hip joint pain in asubject, comprising:

making a first evaluation of the patient's hip joint pain using the painsubscale of Hip Osteoarthritis Outcome Scale (HOOS);

injecting the hip joint of the subject with an injectable aqueousformulation comprising a peptide consisting of an amino acid sequenceTDLQERGDNDISPFSGDGQPFKD (SEQ. ID No:1),

making a second evaluation of hip pain of the patient using HOOS;

whereby the formulation reduces hip joint pain in the subject based onHOOS.

The invention includes uses, including:

A use of a formulation comprising a therapeutically effective amount ofa peptide of SEQ. ID No. 1 alleviating knee pain in a patient diagnosedknee pain when the patient is undergoing an activity which requires agreater degree of knee bending than walking

A use of a peptide in the manufacture of a formulation for alleviatingknee pain in a patient,

wherein the patient is diagnosed with knee pain when the patient isundergoing an activity which requires a greater degree of knee bendingthan walking; and

wherein the peptide consists of sequence TDLQERGDNDISPFSGDGQPFKD (SEQ.ID No:1).

The use as indicted herein where the formulation reduces knee pain inthe subject without improving cartilage structure.

The use as indicted above where the subject is diagnosed with articularcartilage damage.

The use as indicted herein where the formulation reduces knee pain inthe patient in the absence of an observable effect on cartilagestructure.

The use as indicted herein where the administering is by injection.

The use as indicted herein where the injection is a local injection to aknee of the patient.

The use as indicted herein where wherein the injection isintra-articular

The use as indicted herein where the injection is subcutaneous.

The use as indicted herein where wherein the peptide of SEQ ID NO:1 isadministered with a biodegradable matrix carrier.

The use as indicted herein where the biodegradable carrier is abiodegradable collagen sponge.

The use as indicted herein where the peptide of SEQ ID NO: 1 isadministered in combination with hyaluronic acid.

The use as indicted herein where the peptide of SEQ ID NO: 1 isadministered in combination with alginate.

The use as indicted herein where evaluating knee pain in the patienttakes place one month or more after the administering, wherein theevaluating is while the patient is undergoing the motion.

The use as indicted herein where the evaluating is based on a kneeinjury and osteoarthritis outcome score (KOOS).

The use as indicted herein where the evaluating is based on one or moreof patients reported outcomes (PROs) assessing knee pain.

The use as indicted herein where the motion is ascending or descendingstairs.

The use as indicted herein where the administering is repeated pro renata (PRN).

The use as indicted herein where the administering is repeated two ormore times every three days or more for a period of 300 days.

The use as indicted herein where the administering is repeated once eachweek for four times to both of the patient's knees.

The use as indicted herein where the peptide is administered in a dosein a range of 20 mg to 1,200 mg per one injection.

The use as indicted herein where the patient was diagnosed withpatello-femoral osteoarthritis in both knees.

The use as indicted herein where the patient meets all inclusioncriteria herein and does not have any exclusion criteria listed herein.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention is best understood from the following detailed descriptionwhen read in conjunction with the accompanying drawings. It isemphasized that, according to common practice, the various features ofthe drawings are not to-scale. On the contrary, the dimensions of thevarious features are arbitrarily expanded or reduced for clarity.Included in the drawings are the following figures:

FIG. 1 is a graph showing the results of an actual clinical studyshowing changes of knee pain from base line over 12 months based on thepain subscale of knee injury and osteoarthritis outcome score (KOOS).

FIG. 2 is an outline of questions asked to patients in connection withthe study described herein.

FIG. 3 is a graph showing the results obtained in answer to question 1relating to how often knee pain is experienced in each knee.

FIG. 4 is a graph showing the results obtained in answer to question 2relating to the severity of knee pain experienced when twisting/pivotingon each knee in the preceding week.

FIG. 5 is a graph showing the results obtained in answer to question 3relating to the severity of knee pain experienced when straighteningeach knee fully in the preceding week.

FIG. 6 is a graph showing the results obtained in answer to question 4relating to the severity of knee pain experienced when bending each kneefully in the preceding week.

FIG. 7 is a graph showing the results obtained in answer to question 5relating to the severity of knee pain experienced in each knee whenwalking on a flat surface in the preceding week.

FIG. 8 is a graph showing the results obtained in answer to question 6relating to the severity of knee pain experienced in each knee whengoing up or down stairs in the preceding week.

FIG. 9 is a graph showing the results obtained in answer to question 7relating to the severity of knee pain experienced in each knee while inbed in the preceding week.

FIG. 10 is a graph showing the results obtained in answer to question 8relating to the severity of knee pain experienced in each knee whensitting or lying in the preceding week.

FIG. 11 is a graph showing the results obtained in answer to question 9relating to the severity of knee pain experienced in each knee whilestanding up right in the preceding week.

FIG. 12 is a graph showing the results of actual clinical study showingchanges of knee function from base line over 12 months measured by KOOSADL (function of daily living subscale of knee injury and osteoarthritisoutcome score).

DETAILED DESCRIPTION OF THE INVENTION

Before the present methods, uses and formulations are described, it isto be understood that this invention is not limited to particularembodiments described, as such may, of course, vary. It is also to beunderstood that the terminology used herein is for the purpose ofdescribing particular embodiments only, and is not intended to belimiting, since the scope of the present invention will be limited onlyby the appended claims.

Where a range of values is provided, it is understood that eachintervening value, to the tenth of the unit of the lower limit unlessthe context clearly dictates otherwise, between the upper and lowerlimits of that range is also specifically disclosed. Each smaller rangebetween any stated value or intervening value in a stated range and anyother stated or intervening value in that stated range is encompassedwithin the invention. The upper and lower limits of these smaller rangesmay independently be included or excluded in the range, and each rangewhere either, neither or both limits are included in the smaller rangesis also encompassed within the invention, subject to any specificallyexcluded limit in the stated range. Where the stated range includes oneor both of the limits, ranges excluding either or both of those includedlimits are also included in the invention.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although any methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of the present invention, some potential andpreferred methods and materials are now described. All publicationsmentioned herein are incorporated herein by reference to disclose anddescribe the methods and/or materials in connection with which thepublications are cited. It is understood that the present disclosuresupersedes any disclosure of an incorporated publication to the extentthere is a contradiction.

It must be noted that as used herein and in the appended claims, thesingular forms “a”, “an”, and “the” include plural referents unless thecontext clearly dictates otherwise. Thus, for example, reference to “aninjection” includes a plurality of such injections and reference to “themeasurement” includes reference to one or more measurements andequivalents thereof known to those skilled in the art, and so forth.

The publications discussed herein are provided solely for theirdisclosure prior to the filing date of the present application. Nothingherein is to be construed as an admission that the present invention isnot entitled to antedate such publication by virtue of prior invention.Further, the dates of publication provided may be different from theactual publication dates which may need to be independently confirmed.

Joint Pain and its Treatment

Pain associated with arthritis or injuries tends to be felt moreseverely when the joint is under more physical stress. This is commonamong joint disorders such as osteoarthritis, rheumatoid arthritis, andjoint trauma.

Anti-inflammatory agents such as non-steroidal anti-inflammatory drugs(NSAIDs) and analgesic such as acetaminophen are currently used tocontrol joint pain. These drugs tend to work better when the pain ismilder. In more severe cases, these types of agents tend to be lesseffective. As such, opioids are sometimes used to control severe jointpain but opioid use is not desirable or ideal for these patients. Also,in case of NSAIDs, their uses need to be carefully monitored becausethey are known to be associated with multiple adverse effects such askidney malfunction and stomach bleeding. Use of these drugs are oftenavoided by physicians particularly in elderly patients since they mayalready have deteriorated kidney functions.

In the present invention, a method of alleviating joint pain that worksbetter on pain associated with activities involving a higher degree ofstress on the joint is disclosed. The method comprises injecting thepatient with a formulation of a peptide of SEQ ID No. 1 in atherapeutically effective amount. This method particularly works well inalleviating knee pain associated with stress on the knee, without safetyconcerns such as those with opioid analgesic.

The peptide of SEQ ID No. 1 has been known to promote new cartilageformation (See U.S. Pat. No. 8,426,558).

For this activity, the peptide of SEQ ID No. 1 was tested for itsclinical safety and efficacy on a condition involving cartilage damagein a Phase 2 randomized double-blind controlled clinical trial with mildto severe knee osteoarthritis (OA) patients. See EXAMPLES.

For its selective cartilage repair activities, the expected clinicalbenefit of the peptide was improvement of knee functions because bettermovement of a joint could be anticipated if the peptide repairs thedamaged cartilage, makes it resilient and its surface smoother.

On the other hand, pain alleviation was not anticipated since it hasbeen known that the peptide of SEQ ID No. 1 does not have anyanti-inflammatory or analgesic activities.

Also, cartilage repair should not affect any sensations since cartilagedoes not have neurons and there is no inter-cellular connection amongchondrocytes (cartilage cells) embedded in the cartilage tissue.

As expected, knee functions measured by KOOS (Knee injury andOsteoarthritis Outcome Score) and WOMAC (Western Ontario and McMasterUniversities Osteoarthritis Index) demonstrated clinically meaningfuland highly statistically significant (p=0.008) improvement in the kneestreated with the peptide of SEQ ID No. 1 as compared to theplacebo-treated knees at both 6 and 12-month time points aftertreatment. See FIG. 12.

The KOOS ADL (Function of Daily Living) consists of 17 questions askingdegree of difficulty in functioning each knee during 17 differentactivities in daily living. Those 17 activities are broadly ranged fromlight to heavy duties. With regard to each activity, difficulty of eachknee function is scored in 0-4 range where 0 as no difficulty and 4 asthe most difficulty. The sum of the scores range from 0 to 68 (4×17),which is then converted to a 0-100 scale is KOOS ADL score. WOMACfunction consists of the same questions with same scoring, except thetotal score range is not converted to 0-100 but remains 0-68.

The function improvement in the knee treated with the peptide of SEQ IDNo. 1 as compared to placebo-treated knee was observed in most of the 17light to heavy activities.

Further, the KOOS ADL (and WOMAC function) improvement tend to be moreextensive in the group of subjects who demonstrated larger cartilagevolume increase as compared to the group that cartilage volume changewas negative or neutral.

These observations were within the earlier expectation that structuralimprovement cartilage should improve knee functions.

Knee pain was measured by KOOS pain and WOMAC pain scores.

The KOOS pain domain consists of 9 questions and each question is scoredin 0-4 range. The sum of the scores, 0-36 (4×9), which is converted to a0-100 scale to generate a KOOS pain score. While the first of the 9questions asks for the frequency of knee pain, the other 8 questions askfor severity of knee pain during different activities or positions,where 0 is “never” experiencing pain and 4 is “always” experiencingpain. These 8 activities range from positions with little to no motionsuch as “at night while in bed” to those with high joint loading such as“going up or down stairs” (See FIG. 2). WOMAC pain consists of the samequestions with the same scoring, except that the total score is notconverted to a 100-point scale but remains in the range 0-36.

The total KOOS pain scores were very similar between the knees treatedwith the peptide of SEQ ID No. 1 and the placebo treated knees until 6months after the treatment. At 12 months, the drug-treated knees showeda clinically meaningful improvement in total KOOS pain compared withplacebo-exposed knees, with a trend towards statistical significance(p=0.09).

However, among the 8 statuses where the severity of knee pain wasmeasured, only pain “going up or down stairs” showed statisticallysignificant improvement in the knee treated with the peptide of SEQ IDNo. 1 as compared to the placebo-treated knee, and the statisticalsignificance was robust (p=0.004) (See FIG. 8).

“Going up or down stairs” is an activity that is associated with thegreatest load to knee cartilage among the 8 activities of the KOOS painscore questions. The peak patella-femoral joint contact force isapproximately 8 times higher during stair ascent than during walking ona level surface (Costigan, 2002).

It was surprising that the peptide of SEQ ID No. 1 significantlyalleviated pain associated with only activity with the highest stress tothe knee, and that it did not do so in other activities or statuseswhere the stress to the knee is none or less.

Further, the alleviation of pain “going up or down stairs” did not showany positive correlation with the structural change of cartilage.

This suggests that the pain alleviation by the peptide of SEQ ID No. 1is not due to its cartilage repair activity.

As described above, it is known that the peptide of SEQ ID No. 1 doesnot have any anti-inflammatory or analgesic activities.

Thus, the alleviation of pain “going up or down stairs” by the peptideof SEQ ID No. 1 is for an unknown alternative mechanism triggered byadministration of the peptide.

It is known that knee pain is not necessarily correlated with degree ofknee cartilage destruction. There are patients who claim severe kneepain with little to no damage on their knee cartilage. On the otherhand, there are severe radiographic arthritis patients with significantdamage on their knee cartilage who do not feel knee pain at all.

Therefore, it is not unreasonable to determine that the pain alleviationproperty of the peptide of SEQ ID No. 1 is independent from its knowncartilage repair activity.

The only other activity which the peptide of SEQ ID No. 1 showed nearstatistically significant pain alleviation was “bending knee fully”(P=0.07) (See FIG. 6). Knee bending is an activity that increases thestress on knee cartilage, though to a lesser extent than the stressassociated with “going up or down stairs”. It is reasonable to assumethe pain on knee bending is similar, if not as severe, to that of stairclimbing and descent.

The peptide of SEQ ID No. 1 did not show pain alleviation withstatistical significance or trend in other activities or statuses.

In the meantime, it should be noted that the frequency of knee pain wassignificantly reduced by the peptide of SEQ ID No. 1. Although thepeptide alleviates pain at selected activities, the patients must noticethat overall frequency of pain was reduced by the treatment.

Pain going up or down stairs is one of the most common complaints by thepatients whose knees are affected by osteoarthritis, rheumatoidarthritis, and knee trauma.

The unique pain alleviation property of the peptide of SEQ ID No. 1should be highly useful to treat pain in these populations because thepain with higher stress to the knee is more difficult to control by thecurrent most widely used pain therapeutics such as NSAIDs andacetaminophen.

Further, the peptide of SEQ ID No. 1 should alleviate pain in otherjoints than knee when such joints are exerted a pressure or force.

EXAMPLES

The following examples are put forth so as to provide those of ordinaryskill in the art with a complete disclosure and description of how tomake and use the present invention, and are not intended to limit thescope of what the inventors regard as their invention nor are theyintended to represent that the experiments below are all or the onlyexperiments performed. Efforts have been made to ensure accuracy withrespect to numbers used (e.g. amounts, temperature, etc.) but someexperimental errors and deviations should be accounted for. Unlessindicated otherwise, parts are parts by weight, molecular weight isweight average molecular weight, temperature is in degrees Centigrade,and pressure is at or near atmospheric.

EXAMPLE 1

A Randomized Double-blind Placebo Control Study of TPX-100 in thePatients with Osteoarthritis of the Knees

Clinical Study Methodology

Outline of the Study

A multicenter, randomized double-blind, placebo controlled study wasdesigned to investigate the safety, tolerability, pharmacokinetics, andefficacy of TPX-100 administered in four weekly doses in subjects withbilateral patello-femoral knee osteoarthritis. The study was conductedunder an open IND (investigational new drug application) at CDER (Centerfor Drug Evaluation and Research) of the U.S. FDA (The United StatesFood and Drug Administration) in compliance with GCP (Good ClinicalPractice) and ICH (International Conference on Harmonization ofTechnical Requirements for Registration of Pharmaceuticals for HumanUse) guidelines. Eighteen (18) orthopedic, rheumatologic and familypractice centers in the U.S. participated in the study.

The study was divided into Part A and Part B. The Part A was to evaluatesafety of intra-articular (I.A.) administration of TPX-100 at differentdosing levels (20, 50, 100, or 200 mg per injection in sequentialcohorts) in the subjects with osteoarthritis of the knees and to selecta dose adopted for the Part B. The Part B was to evaluate safety andefficacy of the selected dose of TPX-100.

Subjects in Part A enrolled in sequential cohorts were randomized toreceive 20, 50, 100 or 200 mg of TPX-100 in one knee and identicalplacebo in the contralateral knee. Active and placebo assignments wererandomized, with subject, site, and sponsor blinded as to treatmentassignment. A Safety Review Committee (SRC) evaluated safety in eachdosing cohort. The SRC assessed safety and dose-limiting toxicities, ifevident, and determined whether the next higher dosing regimen might beenrolled. Part A were completed and analyzed with regard to safety priorto dose selection and initiation of Part B.

Part A included four (4) intra-articular (I.A.) injections, one perweek, in sequential dosing cohorts of 20, 50, 100 and 200 mg TPX-100versus placebo. Six (6) subjects were enrolled in 20, 50, and 100 mgcohorts, respectively, and nine (9) subjects were enrolled in 200 mgcohort. Each dosing cohort was reviewed based on safety analysis of dosegroups in Part A.

The 200 mg dose was selected for Part B based on review and approval bythe SRC. There were no dose-limiting toxicities for this dose or the 3lower doses investigated in Part A. Eighty-seven (87) subjects wereregistered in Part B (200 mg dose) and combined with the nine subjectsin the 200 mg cohort of Part A for the final drug efficacy analysis. Thecombined final number of the subjects that were analyzed for the drugefficacy for 200 mg dose of TPX-100 was 93.

In both Part A and Part B, subjects received 4, once-weekly doses ofactive drug in the knee randomized to active drug in the Index knee andplacebo in the contralateral (Control) knee, delivered by theintra-articular route. No other doses of drug or placebo wereadministered. All subjects visited their respective clinical sites at 3,6, and 12 months after the first dosing for their safety and efficacyassessments.

Screening of the Subjects

After informed consent was obtained, subjects underwent a clinical andlaboratory screening evaluation at which their preliminary eligibilityfor the study was evaluated. Screening included following procedures:

-   -   Medical history including medication history    -   Focused physical examination    -   Vital signs including resting blood pressure, pulse, respiratory        rate, and temperature    -   Weight, height, and BMI    -   X-ray of the knees (if not obtained within 3 months of        screening)    -   Laboratory evaluations including hematology, coagulation        profile, comprehensive metabolic panel, etc.    -   Recording of concomitant medications

Subjects who met all clinical and laboratory eligibility criteriaunderwent standardized bilateral knee MRIs.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria for screening of the subjects foreither Part A or Part B were as follows:

Inclusion Criteria

-   -   1. Age ≥25 and ≤75    -   2. Patello-femoral osteoarthritis of both knees of mild to        moderate severity with intact meniscus and ligamentous stability        (cruciate and collateral ligaments)        -   Clinically, as determined by screening questionnaire,            judgment of the Principal Investigator (may be supporting by            imaging studies of knees); confirmed by centrally read            screening MRI of both knees, of ICRS Grade 1-3, or Grade 4            with only focal defects, no defect greater than 1 cm.        -   Meniscus intact (MRI degenerative signal up to and including            grade II acceptable)        -   Cruciate and collateral ligament stability as defined by            clinical examination    -   3. Able to read, understand, sign and date the subject informed        consent    -   4. Willingness to use only acetaminophen as the primary        analgesic (pain-relieving) study medication. The maximum dose of        acetaminophen must not exceed 4 grams/day (4000 mg) per day.    -   5. Willingness to use only hydrocodone/acetaminophen or        hydrocodone alone for breakthrough pain during the injection        period (through study day 30).    -   6. Willingness not to use non-steroidal anti-inflammatory drugs        (NSAIDS) such as aspirin, ibuprofen or naproxen for the first 30        days of the study.    -   7. Female subjects of child bearing potential who are sexually        active (non-abstinent) must agree to and comply with using 2        highly effective methods of birth control (oral contraceptive,        implant, injectable or indwelling intrauterine device, condom        with spermicide, or sexual abstinence) while participating in        the study.        Exclusion Criteria    -   1. Contraindication to MRI, including: metallic fragments, clips        or devices in the brain, eye, or spinal canal; implanted devices        that are magnetically programmed; weight >300 lbs.; moderate or        severe claustrophobia; previous intolerance of MRI procedure    -   2. ICRS greater than Grade 3, excepting Grade 4 with focal        defects no greater than 1 cm as confirmed by centrally-read        screening MRI    -   3. MRI evidence of inflammatory or hypertrophic synovitis, or        significant chondral calcification    -   4. Prior surgery in the knees, excluding procedures for        debridement only    -   5. Knee joint replacement or any other knee surgery planned in        the next 12 months    -   6. History of rheumatoid arthritis, psoriatic arthritis, or any        other autoimmune or infectious cause for arthritis    -   7. Knee effusion >2+ on the following clinical scale:        -   Zero=No wave produced on downstroke        -   Trace=Small wave on medial side with downstroke        -   1+=Larger bulge on medial side with downstroke        -   2+=Effusion spontaneously returns to medial side after            upstroke (no downstroke necessary)        -   3+=So much fluid that it is not possible to move the            effusion out of the medial aspect of the knee    -   8. Last viscosupplementation (e.g. Synvisc® or similar        hyaluronic acid product) injected into either knee <3 months        before screening    -   9. Last intra-articular knee injection of corticosteroids <2        months before screening    -   10. Use of any steroids (except inhaled corticosteroids for        respiratory problems) during the previous month before screening    -   11. Known hypersensitivity to TPX-100    -   12. Known hypersensitivity to acetaminophen or hydrocodone    -   13. History of arthroscopy in either knee in the last 3 months        before screening    -   14. History of septic arthritis, gout or pseudo-gout, of either        knee in previous year before screening    -   15. Clinical signs of acute meniscal tear (e.g. locking or new        acute mechanical symptoms consistent with meniscal tear)    -   16. Patellar chondrocalcinosis on X-Ray    -   17. Skin problem, rash or hypersensitivity, affecting either        knee at the injection site    -   18. Bleeding problem, platelet or coagulation deficiency        contraindicating intra-articular injection    -   19. Active systemic infection    -   20. Current treatment or treatment within the previous 2 years        prior to the Screening Visit for any malignancy except basal        cell or squamous cell carcinoma of the skin, unless specific        written permission is provided by the Sponsor's medical monitor    -   21. Women of childbearing potential who are pregnant, nursing,        or planning to become pregnant, and those who do not agree to        remain on an acceptable method of birth control throughout the        entire study period    -   22. Participation in other clinical osteoarthritis drug studies,        with the exception of analgesic studies, within one year prior        to screening    -   23. Currently taking Paclitaxel (mitotic inhibitor), and or        Natalizumab (anti-integrin).    -   24. History of significant liver disease or consumption of more        than 3 alcoholic drinks a day. (Definition of one alcoholic        drink: 12-ounces of beer, 8-ounces of malt liquor, 5-ounces of        wine, 1.5-ounces or a “shot” of 80-proof distilled spirits or        liquor such as gin, rum, vodka, or whiskey).        Randomization

MRIs of both knees were evaluated by a central reader to determine theICRS grade (gICRS) of each knee. If the cartilage of patello-femoralcompartment in both knees fell within ICRS grades 1-3, or 4 with onlyfocal defects, no defects greater than 1 cm, and all other inclusioncriteria were met, with none of the exclusion criteria, the subject wasregistered. The randomization center randomized each subject to eitherRight knee active or Left knee active, with the active knee to receiveTPX-100 and the contralateral knee to receive identical placebo.

For enrolled subjects, there was within-subject randomization, such thatone knee received active drug injections, and the contralateral kneereceived identical placebo injections. Using subjects as their owncontrol permits reduction of confounders such as weight, activity level,pain threshold, and uncharacterized genetic susceptibilities to OAprogression. As two knees within a person form a matched set, theeffects of individual-level confounders that are difficult to quantify(e.g. level of activity, genetic and epigenetic factors, pain threshold)are eliminated, increasing the power of the study to detect a treatmenteffect if one is present.

Any subject who was randomized in Part A was excluded from enrollment inPart B.

Dosing

On the first dosing day, the randomized subjects were assessed for theirgeneral health conditions by physical examinations and vital signs.Further, they completed self-reported assessments of the conditions ofeach of their knees as well as systemic health by the questionnaires ofKOOS (Knee injury and Osteoarthritis Outcome Score), which includessubscales of WOMAC (Western Ontario and McMaster UniversitiesOsteoarthritis Index). KOOS is a questionnaire that assessesknee-specific activities of daily living, sports and recreationfunction, knee-related quality of life, symptom, and knee pain. The KOOShas been used extensively in longitudinal studies of kneeosteoarthritis. After these assessments, subjects received oneintra-articular injection in each knee, with each injection preparedfrom the vial(s) marked for that knee. One knee received TPX-100, andthe contralateral knee received placebo, in a triple-blind fashion(subject, site, and sponsor all blinded to treatment assignment).Subjects were monitored for adverse events during the injections and fora few hours after the injections. Vital signs were also monitored afterthe injections.

On the 7th, 14th, and 21st days after the first dosing, subjectsreceived the second, third, and fourth (last) dosing of the same studymaterials, respectively, as well as safety and adverse event assessmentsin the same way as the first dosing day.

Post-treatment Follow-up

Subjects returned to their respective study sites at 3, 6 and 12 monthsafter the first dosing day for follow-up evaluations. In addition, thestudy sites monitored the subject's condition through telephone contact9 months after the first dosing day. During the 3, 6, and 12 monthspost-treatment follow-up on-site visits, subjects were evaluated byphysical examination, vital signs, serum chemistry, as well as KOOS.Adverse events and concomitant medications were also recorded. Further,during the 6 and 12 month visits, MRI of both knees were taken.

Efficacy Analyses

All KOOS subscale scores were analyzed. The primary analysis was carriedout using a two-sided paired t-test at the 5% level of significance. Theoutcome variable was the difference between the change of the score ofeach subscale of KOOS from baseline in the treated knee (“Index Knee”)and the change from baseline in the placebo-treated knee (“ControlKnee”).

Results

Ninety-three (93) subjects who received 200 mg per dose of TPX-100 inone knee and placebo in contralateral knee were analyzed for efficacy.

Approximately 40% of all knees had gICRS 4 (the most severe) knee OA,all of which were in the tibio-femoral (TF) compartment, anotherapproximately 40% had gICRS 3 (the second most severe) knee OA in bothor either of patello-femoral (PF) and/or TF compartments, and theremaining approximately 20% had gICRS 2 (moderate) knee OA in both oreither of PF and/or TF compartments. There were no gICRS 1 knee OAsubjects. The mean body mass index (BMI) of all subjects exceeded 30,which is an obesity range. The average age of the subjects was 58.1, and58% of the subjects were female. In summary, the demographic of thesubjects in the study was very similar to that of knee OA population inthe U.S., and relatively on severe side.

The TPX-100 treatments were safe and well tolerated throughout the studyperiod. There were no severe adverse events likely or possibly relatedto the drug treatment. Treatment-related adverse events were mild ormoderate, transient, and common in many subjects at baseline.

Several patient reported outcomes (PROs) including a majority of KOOSsubscales exhibited clinically meaningful and statistically significantimprovements in the Index (TPX-100 treated) knees as compared to theControl (placebo treated) knees.

The KOOS ADL (Function of Daily Living) subscale consists of 17questions regarding various daily activities and is known to indicateday-to-day knee functions. The KOOS ADL demonstrated clinicallymeaningful and statistically significant (p<0.05) improvement in Indexknees as compared to Control knees at both 6 and 12 month time points.See FIG. 12.

The KOOS Sports and Recreation subscale consists of five questionsregarding harder sporting activities such as jumping, running, andsquatting. The KOOS Sports and Recreation showed clinically meaningfuland statistically significant improvement in Index knees as compared toControl knees at 6 months.

The KOOS knee related quality of life (QOL) subscale consists of fourquestions asking about the subjects' levels of confidence regarding eachof their knees. The KOOS knee related QOL exhibited clinicallymeaningful and statistically significant improvement in Index knees ascompared to Control knees at 12 months.

The KOOS Pain subscale consists of 9 questions asking 1) frequency ofpain and 2) severity of pain when the subject does different activities.The KOOS Pain demonstrated clinically meaningful and statistical trend(p<0.09) of improvement in Index knees as compared to Control knees at12 months.

Following are the 9 questions that consist the KOOS Pain subscale:

1. How often do you experience RIGHT/LEFT knee pain? (see FIG. 3) Never(0), Monthly (1), Weekly (2), Daily (3), Always (4)

What amount of RIGHT/LEFT knee pain have you experienced the last weekduring the following activities?

-   None (0), Mild (1), Moderate (2), Severe (3), Extreme (4)

2. Twisting/pivoting on your knee (see FIG. 4)

3. Straightening knee fully moving (see FIG. 5)

4. Bending knee fully (see FIG. 6)

5. Walking on flat surface (see FIG. 7)

6. Going up or down stairs (see FIG. 8)

7. At night while in bed (see FIG. 9)

8. Sitting or lying (see FIG. 10)

9. Standing upright (see FIG. 11)

Analyzing severity of pain in each of these activities, improvementsassociated with “Going up or down stairs” (Question #6) were highlysignificant in Index (drug-treated) knees as compared to Control(placebo-treated) knees (p=0.004) at 12 months, while pain at any otheractivities at any time point did not show statistically significantimprovements in Index knees as compared to Control knees (See Table 1).Further, the margin of pain score improvement in Index knees as comparedto Control knees was outstanding in the “Going up or down stairs” ascompared to that in other activities (See Table 1).

TABLE 1 Pain When Going up or down Stairs is Particularly Improved asCompared to Pain in Other Activities Score Change from Baseline to 12Months No. Question Index Control Difference p-value 1 How often do youexperience −0.62 −0.37 −0.26 0.04 RIGHT/LEFT knee pain? What amount ofRIGHT/LEFT knee pain have you experienced last week during the followingactivities? 2 Twisting/pivoting on your knee −0.19 −0.11 −0.09 0.52 3Straightening knee fully moving −0.30 −0.18 −0.12 0.27 4 Bending kneefully −0.45 −0.22 −0.24 0.07 5 Walking on flat surface −0.25 −0.13 −0.120.29 6 Going up or down stairs −0.51 −0.17 −0.33 0.004 7 At night whilein bed −0.19 −0.19 0.00 1.00 8 Sitting or lying −0.26 −0.24 −0.02 0.84 9Standing upright −0.34 −0.18 −0.16 0.15 [Notes] 1) Index = TPX-100treated knees; Control = Placebo treated knees. 2) Neither subjects norcaregivers knew which knee (RIGHT/LEFT) received TPX-100 or Placebothroughout the entire study period. 3) Negative score change meansfrequency (for Question 1) or severity (for Questions 2-9) of pain wasdecreased. 4) Difference = [Index score change] − [Control scorechange]. More negative number means more improvement in Index knee ascompared to Control. 5) Among eight different activities (Questions2-9), Going up or down stairs (Question 6) was the only activity thatshowed statistically significant (p < 0.05) pain reduction in Indexknees as compared to Control, and the degree of significance wasoutstanding. 6) Overall frequency of knee pain (Question 1) also showedstatistically significant improvement in Index knees as compared toControl.

The observed improvements in knee functions and overall knee healthconditions as demonstrated by KOOS ADL, KOOS Sports & Recreation, andKOOS Knee-related QOL were reasonably predicted from knee cartilagerepair activities demonstrated in the prior non-clinical (goat model)studies (See U.S. Pat. No. 8,426,558), because, theoretically,regeneration of healthy cartilage should make the knee joint movementsmoother.

On the other hand, the observed significant improvement in pain wasunexpected. First, cartilage contains no nerve supply, therefore,cartilage repair or regeneration would not affect pain scores. Second,TPX-100 does not have any analgesic or anti-inflammatory activities.

Among the eight activities (#2-9) making up the KOOS Pain score, “Goingup or down stairs” involves a patella-femoral joint contact forceapproximately 8 times higher during stair ascent than during walking ona level surface (Costigan Pa., 2002). It was surprising and unexpectedfinding that TPX-100 treatment improved pain scores in the activityassociated with greatest patella-femoral cartilage stress among theeight activities making up the KOOS pain score. Only pain at “Bendingknee fully” showed a trend (p<0.09) of improvement.

Knee pain at going up or down stairs is one of the most commoncomplaints that rheumatologists, orthopedists, and sports medicinedoctors hear from their patients in association with cartilage disease,whether from OA, rheumatoid arthritis, or joint trauma. In addition,this knee pain has been found to be among the earliest signs of kneeosteoarthritis (Hensor E M, 2015). This particular result suggests thatTPX-100 may be useful treating knee pain when going up or down stairs,regardless of the pathology of such knee pain.

Also, it should be noted that frequency of overall knee pain (Question#1) was significantly improved (p=0.04) in Index knees compared withControl knees at 12 months. This suggests that improvement in pain“Going up or down stairs” contributes substantially to overall pain inknee osteoarthritis.

Thus, TPX-100 presents a new method to treat pain in the knee inarthritic or other pathologic or traumatic conditions by alleviating thepain when going up or down stairs.

REFERENCES

-   Bedson and Croft, BMC Musculoskeletal Disorders 2008, 9:116 doi:    10.1186/1471-2474-9-116-   Buckwalter J A. Articular cartilage injuries. Clin Orthop Relat Res    2002; 21-37-   Chevalier X, et al. Single, intra-articular treatment with 6 cc    hylan G-F 20 in subjects with symptomatic primary osteoarthritis of    the knee: a randomized, multi-centre, double-blind, placebo    controlled trial. Ann Rheum Dis 2010; 69: 113-119.-   Cohen MD. Hyaluronic acid treatment (viscosupplementation) for OA of    the knee. Bull Rheum Dis. 1998; 47; 4-7.-   Costigan P A, Deluzio K J, Wyss U P. Knee and hip kinetics during    normal stair climbing. Gait Posture. 2002 Aug.; 16(1):31-7.-   Davies A P. The Radiologic Prevalence of Patellofemoral    Osteoarthritis. Clinical Orthopaedics and Related Research. 2002;    402; 206-212-   Hensor E M, Dube B, Kingsbury S R, Tennant A, Conaghan P G. Toward a    Clinical Definition of Early Osteoarthritis: Onset of    Patient-Reported Knee Pain Begins on Stairs. Data from the    Osteoarthritis Initiative. Arthritis Care Res (Hoboken). 2015    January; 67(1):40-7. doi: 10.100²/_(a)cr.22418-   Lankhorst N E, et. al. Incidence, Prevalence, Natural Course and    Prognosis of Patellofemoral Osteoarthritis: the Cohort Hip and    Cohort Knee Study, Osteoarthritis and Cartilage. 2017; 25(5):647-653-   McAlindon T E, et. al. Effect of Intra-articular Triamcinolone vs    Saline on Knee Cartilage Volume and Pain in Patients with Knee    Osteoarthritis, A Randomized Clinical Trial. JAMA 2017;    319(19):1967-1975.doi:10.1001/jama.2017.5283-   Niemeyer M D, et al. Characteristic Complications After Autologous    Chondrocyte Implantation for Cartilage Defects of the Knee Joint. Am    J Sports Med 2008: 36:2091-2099-   Woolf A D, Pfleger B, Burden of major musculoskeletal conditions.    Bulletin of the World Health Organization 2003; 81 (9): 646-56.

Zaslav K, et al. A prospective study of autologous chondrocyteimplantation in subjects with failed prior treatment for articularcartilage defect of the knee: Results of the Study of the Treatment ofArticular Repair (STAR) clinical trial. Am J Sports Med. 2009; 37:42-55.

The preceding merely illustrates the principles of the invention. Itwill be appreciated that those skilled in the art will be able to devisevarious arrangements which, although not explicitly described or shownherein, embody the principles of the invention and are included withinits spirit and scope. Furthermore, all examples and conditional languagerecited herein are principally intended to aid the reader inunderstanding the principles of the invention and the conceptscontributed by the inventors to furthering the art, and are to beconstrued as being without limitation to such specifically recitedexamples and conditions. Moreover, all statements herein recitingprinciples, aspects, and embodiments of the invention as well asspecific examples thereof, are intended to encompass both structural andfunctional equivalents thereof. Additionally, it is intended that suchequivalents include both currently known equivalents and equivalentsdeveloped in the future, i.e., any elements developed that perform thesame function, regardless of structure. The scope of the presentinvention, therefore, is not intended to be limited to the exemplaryembodiments shown and described herein. Rather, the scope and spirit ofpresent invention is embodied by the appended claims.

The invention claimed is:
 1. A method for managing joint pain in asubject, comprising: combining water with a peptide consisting of anamino acid sequence TDLQERGDNDISPFSGDGQPFKD (SEQ ID NO: 1) to create aninjectable aqueous formulation; and injecting a joint of the subjectwith the injectable aqueous formulation, whereby the formulation reducesjoint pain in the subject.
 2. The method of claim 1, where the subjectsuffers from at least one of osteoarthritis, rheumatoid arthritis, orjoint trauma in the joint with the pain.
 3. The method of claim 1,wherein the peptide of SEQ ID NO: 1 is administered in combination withhyaluronic acid; and wherein the peptide is administered in a dose in arange of 100 mg to 400 mg per one injection, and administered once perweek for three weeks.
 4. A method for managing joint pain in a humansubject diagnosed with joint pain, comprising: combining water with apeptide consisting of an amino acid sequence TDLQERGDNDISPFSGDGQPFKD(SEQ ID NO: 1) to create an injectable aqueous formulation; andinjecting a joint of the subject with the injectable aqueous formulationwherein the peptide is administered in a dose in a range of 20 mg to1,200 mg per one injection, whereby the formulation reduces joint painin the subject.
 5. A method for managing joint pain in a human subjectdiagnosed with at least one of osteoarthritis, rheumatoid arthritis, orjoint trauma in the joint with the pain when the subject is undergoingan activity which stresses the joint, comprising: combining water with apeptide consisting of an amino acid sequence TDLQERGDNDISPFSGDGQPFKD(SEQ ID NO: 1) to create an injectable aqueous formulation; andinjecting a joint of the subject with the injectable aqueous formulationwherein the peptide is administered in a dose in a range of 20 mg to1,200 mg per one injection, and the injecting is once per week, wherebythe formulation reduces joint pain in the subject.